NOTHING BUT THE TOOTH: When do you see an orthodontist?

Thursday

Readers ask if age 9 is too young to see an orthodontist, and if a night-guard is the right approach for a man's loose teeth.

Q. I just read your column in the Tri-Town Transcript and I do indeed have a question.

My son is 9, and our dentist, who I like very much, has suggested he go see an orthodontist. She says he had baby teeth still on the bottom which are getting in the way of the adult teeth coming in. She says the orthodontist will suggest a treatment plan.

It seems to me very early to be seeing an orthodontist. When I was a kid, you saw the orthodontist when you were in middle school, not elementary age.

We live in a town that has high median incomes. I feel like if I lived in a less affluent town, my dentist wouldn’t be making this suggestion. Right? I am concerned with the cost of the orthodontist. I am also feeling guilty that I have not yet taken him.

Part 2 to my question: How should I shop for an orthodontist that we can afford?

I want to take the best care of my child and his teeth. We go to the dentist regularly and truly believe good dental health is important.

A. I believe your dentist is taking the correct approach. She sees that there are over-retained baby teeth and recognizes that this may be a problem. If left as is, these baby teeth can cause a permanent tooth to erupt in an adverse way. It is excellent that your dentist has noticed it and wants an opinion from the orthodontic specialist as to whether early intervention is the proper approach.

I can understand your concern as to cost but if your dentist provides you with the information necessary for you to bring along, i.e. notes, X-rays, models if appropriate and maybe has a verbal conversation with the orthodontist, I believe the decision can be made easily with a minimal consultation fee.

In practice, the earlier the dentist sees that orthodontic treatment may be needed, the better it is for you and your child. Often the specialist will be able to make recommendations that will make the actual case, if and when needed, go more smoothly.

I believe you should be open with your dentist as to your financial concerns. Your dentist will be able to give you an idea of fee range for orthodontists in your area. This may include seeking orthodontic treatment in a dental school environment where it may take more time but usually fees are far less.

It seems to me that you have made a good selection for a general dentist and you should be open and honest just as you have been with me. Until and unless proven otherwise, trust that these practitioners will treat you and your family in a professional and ethical manner.

Q. My husband and I are in our late 50s and take very good care of our teeth. We get cleanings every six months and floss on a regular basis. Recently our dentist informed my husband that he had several loose teeth and is assuming it’s due to grinding. They also thought it could be from sleep apnea but he definitely doesn’t have that. They have suggested he get a mouth guard made by the dentist, which costs $800 which seems very expensive. We don’t have dental insurance and need to find another avenue.

I asked our hygienist what the difference was between the mouth guard they’re going to make versus the ones you can buy (take a mold of your teeth and send it back for them to make). She said there was a huge difference and the other kind wouldn’t work. What’s your opinion on this cost and is it worth getting it from the dentist or do it on our own?

A. One of the statements you heard the dentist say makes me somewhat concerned as to the diagnosis. The sleep apnea reference is totally incorrect. Sleep apnea is a breathing disorder usually associated with snoring but has no correlation with clenching, grinding or causing teeth to loosen. Also, the hygienist’s answer to your question above leads me to think there is another motive operating here one that may not have your dental health as a priority. Of course I am assuming you are accurate in your statements or interpretations of them.

Teeth do not suddenly loosen. One cause for loose teeth is periodontal disease when long-term chronic inflammation causes loss of supporting bone around a tooth or teeth. This usually takes years to show an effect and since you are being seen regularly, it would have had to be missed repeatedly.

Another is that one tooth may be hitting against another in a very negative manner. This will cause slight mobility and sometimes sensitivity. Usually, the dentist can perform a prudent adjustment of the biting force and this can relieve this excess. The mobility may then disappear.

If there is evidence that your husband is clenching and grinding it could be during the day or during the night. If during the day, he can be alerted and may find this is a habit pattern. Teeth should always be apart unless you are swallowing or chewing. If his are not then he is clenching and this could be the problem. He could also be doing it at night and you might hear him or he may wake up sore in the morning. The areas just in front, under and behind the ears might become tender to touch or tender on opening and closing and this could corroborate clenching and/or grinding.

I would get a second opinion from a practitioner with experience in bite or occlusal analysis. It could be a general dentist or maybe a specialist in periodontal treatment. These specialists see bone loss and consequent mobility a bit more often than a general dentist.

If a night-guard is the treatment recommended, I agree that one professionally fabricated and fitted is more likely to give the desired result. Taking impressions of your mouth is critical and the design created should be unique to your husband’s situation both habit-wise or bite-wise. You can be more casual about a mouth-guard that is made to limit a sports injury, but one for clenching or grinding is far more detailed. It has to fit perfectly with a hard flat biting surface and needs to be fit by the dentist when it comes back from the laboratory.

I cannot comment on the fee with any accuracy. That is for you to discuss with your doctor. It does take time and I have heard of fees from $600 up to $2,000. Again, the fee is set by the doctor and has nothing to do with how well the guard is done. It all depends on what the doctor wants to charge. I have seen lesser expensive guards done better than the higher priced one. I would ask around and expect the kind of explanation I have given to be discussed with you and your husband, no matter what the fee.

Dr. Richard Greenberg of Ipswich practiced dentistry for 45 years after having attended dental school at Columbia University, where he was later an associate clinical professor of restorative dentistry and facilitator of the course of ethics. Do you have a dental question? Email him at dr.richard@nothingbutthetooth.org.